#64

Sara from FiLiA in conversation with Dr Susan Bewley. Women and Health.

Sara: Welcome to the FiLiA Podcasts. My name is Sara. I'm one of the volunteers, and I'm sitting here with Professor Susan Bewley. Susan, thank you so much for joining us for our podcasts. Would you mind just telling us a little bit about yourself? 

Susan: I'm Susan Bewley. I'm an obstetrician gynaecologist who's retired, and I'm an emeritus professor at King's College London in Obstetrics and Women's Health. That's the medical description. I'm a doctor who qualified in 1982 and I then trained in obstetrics and gynaecology. That's the specialty that deals with pregnancy and all the diseases of the reproductive organs. I got an exam in 1987 and then went on to be a consultant at Guys and St. Thomas' Hospital for 17 years.

I particularly worked in high risk maternal and foetal medicine. That's really complicated pregnancies and I did a lot of research on violence against women, and so I guess that my field is women's health. My special interests of severely ill women and women experiencing violence and abuse. 

Sara:  May I ask you a question? Would you call yourself a feminist? 

Susan: Absolutely I would call myself a feminist. At one point we had an organization of women in gynaecology and obstetrics where we debated the F word and a lot of women who are absolutely committed to women, committed to women's health, committed to women's justice back in the 1980s, wouldn't call themselves feminists. I would've called myself feminist just as my mother was, but wouldn't call herself a feminist in the 1960s and fifties. And as my grandmother who qualified in medicine had to give up in the 1910s because she got married, would also have been making a blow for women and women's health. So I think there is a continuing golden thread, which is called feminism, but not everyone uses the word.

Sara: Why do you think is? 

Susan: Well, when I was young and there was a second wave of feminism, the people were put down about being bra burning, humourless, extremist, belittled and shamed. And it is part of the reaction to any cause for justice is to put the individuals down. So I think it is, in some people's books is a dirty word.

I just don't understand what other word you have for that branch of humanism, which relates to the sex class of women. 

Sara: And you've obviously specialised in women's health and women's issues. Did your feminism inform your choices to become an obstetrician and gynaecologist and kind of the things that you've been interested in through your career?

Susan: Yes, I think so very much. Partly because the world that I was growing up in had many more unfairnesses, legal unfairnesses. We were still campaigning to protect the very recent 1967 Abortion Act. As a student I was involved in Reclaim the Night marches in trying to get rid of the law on rape in marriage, which was legal in those days.

So it was very different era. And so I was very informed as a student about my views on the world. In clinical practice in the second part of my training, I saw how women were treated by the then very largely male medical establishment. I found myself furious. We were in those days, examining women under anaesthetic without their knowledge. Four to six students queuing up, being told to do it. All the girls had to wear mini-skirts in theatre. 

So even as a student, I was campaigning about these things. It seemed to me that in obstetrics and gynaecology, some of those worst excesses were present. I did do other jobs in genitourinary medicine because that obviously there's other sexual parts of health in contraception that would've been a possibility.

I looked at paediatrics at one point. I did the exams. Not sure that that's what I wanted to do. As it turns out, it's a fantastic specialty because it's important because it has medicine, surgery, endocrinology, and a lot of social determinants of health. And the women really welcomed women-friendly doctors.

So we've moved from a specialty with less than 10% consultants to over 50%. So I think it was very relevant 

Sara: Because you've been working within medicine for some time, how far do you think that we have come in terms of sexism in healthcare and what do you think are some of the biggest women's health challenges at the moment?

Susan: In terms of sexism in healthcare, I think some of the things that were considered acceptable are no longer acceptable. So what I was just explaining about unconsented examinations that's gone in terms of training. I remember I even wrote up a personal view about being sexually assaulted by a consultant and various colleagues and the language and behaviours, a lot of that has gone. 

There is still a big gender pay gap in medicine and still, a lot of the general public attitudes are reflected in the doctors and nurses and midwives. We shouldn't be surprised about that. 

So in terms of what are the biggest women's health challenges now, what I've seen change in a lifetime is a much greater belief in screening and surveillance.

Things that find problems that don't exist, rely on fear over medicalise, lead to over-diagnosis. I've seen, particularly in my own specialty of pregnancy, I've seen women actually be more fearful of pregnancy and birth than they were 40 years ago when they had more social support and less toxic atmosphere around pregnancy.

I've seen the boon of contraception and safe abortion, which is trying to relieve the pressure of unwanted pregnancy, turn into women trying to get pregnant and failing to get pregnant in their late thirties and early forties. So I've seen a rise in infertility. I've seen a rise in complications in pregnancy because of reproductive aging.

We've seen much, too much use of interventions like caesarean sections and instrumental deliveries. So I don't think that, for all the gains, we've actually got a really good, healthy system. The main reason for that is that there's far too much emphasis on the access and treatment end of medicine, and much too little on the public health and prevention and social determinants of ill health, social and commercial determinants of ill health.

So, you know, I look at it in a different way, but the world changed a lot in the 40 years from when I was a medical student. 

Sara: You mentioned quite a number of different kind of academic and professional areas of interest including lots on research. Can I ask just how do you choose what sorts of projects you decide to focus on?

Susan: Well, many of my projects, which turned into conversations or publications or even then research projects start with observations from patients. They start in the privacy of the consultation room. That why have I seen this here today? What did it mean that there was one day there were two women with HIV on the labour ward?

What did it mean on the day that there were two women losing babies from IVF twins? I start by seeing things and noting that that's new or changed. I also am someone who likes to look under stones and look in the dark shadow places, and certainly the tremendous interests I have in violence against pregnant women started from a conversation with a forensic psychiatrist. 

We decided to go and measure it. We did the first study in the UK of violence during pregnancy and why it was so difficult for midwives to ask about it. And we set up services to try and support women who are experiencing domestic violence. So that became a very major project. 

And I think now I look back, I think, how come nobody asked those questions before, but some of it is happenstance, some of it's the time and some of it is opportunities. So I was very lucky to be in a central London teaching hospital with research facilities and eventually head department so able to make things happen. 

Now I am trying to be more parsimonious with my time and resource and I try to catalyse conversations and collaborations where other people aren't doing things. So the things that interest me now are, again, dark places to do with the long term impacts of child sex abuse maybe, or some of the wrongs that are going on in assistive reproduction and IVF, that kind of thing, and where the edges of medicine meet society.

I want to make a contribution that isn't the standard one. Many of my colleagues are making fantastic, huge contribution in the usual disease models, the usual screening and labelling and intervention models. But I'm more interested in the gaps between the standard practices and standard bricks of medicine in society, if that makes sense.

Sara: Yeah, I think that makes sense. And what I find quite interesting is the ability to, I guess, observe and to try and think about things from an individual case, but then to expand and to look at it kind of more systematically. But it sounds to me like a lot of it is about finding that right question or finding something that's interesting to look at.

Susan: Well I think that comes from, first of all, having a discipline around understanding the personal is political, which came back in the 1970s as a student being in a consciousness raising group and reading a lot of the basic feminist textbooks and starting to have that realisation that I'm not alone, and these conversations I'm having with an individual person or a personal relationship or in a family or in a consultation room or in a bar or in the street,

are highly, highly influenced by context and sexism and patriarchy. 

So that was the feminist learning at that these spaces, that used to be considered entirely private and domestic, were political. And then on the other hand, I think that the training you get from research, which is to start very humble, looking for the unknown unknowns, what do I know, what is known and what's not known, and therefore formulating a really good question that is answerable with a whole range, a suite of methodologies is fantastic. I love it when I find new things, even if it's just numbers appearing in a table of frequencies, something nobody else has seen before until you ask its question in that way, or whether it's the rich texted narrative in qualitative research. 

And I also love being wrong, you know, having to change my mind about things. Having to face subjective beliefs and tenets and assumptions that you didn't even know you had, being challenged by data of one sort or another, you know, and it's what makes you change your mind, change your practice, understand things more deeply.

It's taken me a lifetime, a career lifetime to understand that and to learn, you know, the actual art of being a doctor and listening and analysing and, you know, offering an explanation and possibly interventions. But, you know, at the end of my career, I understand what I was doing and realising all the mistakes I made, but it's being able to articulate that is not something I knew when I started off.

Sara: It is interesting. In some ways you would think that the different disciplines kind of maybe involved in feminism versus that of medicine that maybe there could be some tension between the two at times. I don't know if that's something that you've noticed.

Susan: Oh, absolutely. And I think what I find very difficult is that there's obviously a massive range of feminisms and one of the things that's most difficult is realising that you don't hold the same worldview, and I cannot, although I can in a private consultation room with a patient, respect their subjectivity, their beliefs, whether they're political or religious, or about their illnesses and their own long, complicated story and narrative. On the other hand, I have to bring a discipline of objectivity. If a young girl says, I feel fat, and her BMI is 21. Her body mass index is 21. I mean, I can say, I'm sorry you feel fat, but I can also say she's wrong. And of course this is very difficult. How has she got false consciousness? Am I being a powerful doctor?

But you know, I can't not be a doctor. I have legal responsibilities and moral responsibilities. And so I think this clash of the subjective feeling and the objective reality is, very creative tension, but you've got to be aware you've got it. 

Sara: Speaking of medicine versus feminism when the different kinds of approaches, objectivity and subjectivity, would you be able to maybe comment a little bit about whether there's any differences in terms of the methodology perhaps from doing feminist work?

Basically, I'm trying to ask about differences in approach to a problem when you're using a feminist lens perhaps, versus using the lens of coming at it as a doctor and looking at things from a kind of like an evidence-based medicine perspective. 

Susan: Well, I don't know about the feminist methodologies because I don't suppose I would call myself a scholar in that or anything particular.

I do think that in many parts of civic society, the charities, the non-governmental organizations, the activists, the political people on the ground know things before the officials do. It's true that that general practitioners might see what's really going on inside poor housing with more asthma, or they might see new forms of diseases or they might not recognise that someone's coming with depression, but actually she's in a violent relationship with a person with alcoholism, et cetera, et cetera. 

So on the ground there's a lot of individual knowledge and the starting of collective knowledge, which feminists may go out and search, or they may be trying to provide solutions to many of the problems women have, medicine, the profession itself, obviously it's interested in biology and the biological impacts, but it doesn't immediately go and sort social problems out and I don't think it should. I think we are just one of many parts of the grand schemer, and actually we overstep the mark by medicalising all sorts of issues, which we shouldn't, and I think we should stick to our knowledge and art and skills, which are about compassion, listening to the person in front of us and collecting data and using that data. 

Maybe a feminist in medicine or in academia will go and ask questions and produce data on things that other people haven't. You know, it is feminists who set up, with the police, rape and sexual assault centres.

They may not have called themselves feminist, but there were doctors who really cared, passionate about it, to provide a medical help, more than just the criminal justice issues. 

It might be feminists who go and measure the mental health impacts of various problems in society and say the standard solutions and paradigms are wrong.

But I still think what we stick to is biology and scientific methods to produce data which can then go back into society to be helpful because we are really only here, I think, to deal with health in a narrow sense rather than the overarching sense.  

Sara: I don't think we've covered this yet, but what principles do you think each of the two might be able to learn from each other?

What could feminists learn from like evidence-based medicine and what could medicine learn from feminists, if that makes sense? 

Susan: I think what medicine could do from learning from feminists is to understand much more about a group and a class and how they're socialised and how they experience their lives and how that then comes into health.

We've not looked enough at the children's development and the social norms that are social determinants of diseases that will then end up later in our settings, in our clinics and our hospitals. 

So I think actually understanding what it is that drives people and what it is that constrains people. One of the things I learned very late in life was that, you know, if a woman was leaving hospital against advice, we used to make them fill in forms, you know, ‘left against advice’ Most doctors have no understanding that someone who is going home when she's got a life-threatening disease like preeclampsia in pregnancy, is actually more frightened of something else and it's not that she's stupid and not taking our advice, it's probably that her children at home are not safe with her husband. There are things that are worse than the fear of being ill and death in her life.

 So rather than seeing lots of people as non-compliant with my very good advice, we should be actually saying, what else is going on? What happened to you before you came here? What happened? What's going to happen when you go home? and I think we've failed to understand that a lot of the people who don't come or who don't come for their follow-up it's because they can't, because they've got poverty as an issue or they've got competing claims on their times, or they're putting other people's needs before their own.

And so I think medicine has a lot to learn from the absences and silences, which feminism will tell us about in women's lives and women's health and the sort of society we live in. 

On the other hand, it drives me mad, that so many women don't understand data and science, it puts them off because they're considered male activities. They're very competitive, the sciences and medicine, and so we don't use the power that they bring. 

One of the things that I think feminists should be learning from medicine is be much more sceptical about the data. There's a huge amount of marketing and hype. Women are supposed to think that their bodies are falling apart at all times, that therefore they need screening or whatever.

 I'm very critical of many of the screening programs that overstate their case about what they're doing. And if you look, there is in fact a tremendous distortion in research charities for money. So cancer is by comparison with mental health, let's say, cancer gets a lot more money. It gets a lot more attention and breast cancer in particular, but actually it's been revolutionised since I was a medical student. The death rates have fallen fantastically and it's not where the money should be applied, but, it's considered anti-feminist to say anything anti breast cancer initiatives. 

When I see how many women use alternative and complimentary therapies, how many women don't understand cause and effect how many people believe in before and after testing I sometimes just despair because of course we try and explain the world. I was feeling like this. X happened, I felt better, therefore X made me better. And it's so basic to do with very poor education, but science education passes and mathematical education passes so many good women by and that distresses me.

Sara: And it strikes me that sometimes also, even when you're trying to make your case, for example, if you're arguing from a feminist perspective, it's helpful to have the data perhaps to back your facts.

Susan: You are speaking to a data geek. I love data, data's everything and just measuring is a way of starting to influence the world if you measure things and then you can show changes and if you don't measure what you can't measure doesn't count. What you don't measure doesn't count. 

One of the most striking things I remember reading in the Lancet was an initiative to get every person, every birth registered all around the world. There are people who do not exist officially, legally, because we don't even count them in and out at birth and death.

And so I think it's part of the great human project that we all count and obviously in my field, birth and death and death before birth, let alone shortly after birth, is very relevant to pregnancy and maternal mortality rates. Women who die in pregnancy are a hundred fold differences in different parts of the world, and, you know, women who are having babies still need lots of medical help to keep it as safe as it is in this country.

I love data and seeing changes in data, seeing maternal mortality go up rather than down, or seeing life expectancy flatten, which it's done recently. Really important. It's telling us incredibly important stuff that some of the powers of being are not so keen to hear about.

Sara: And on the subject of kind of education, et cetera, what advice would you give for women who are interested in kind of working in the field of women's health especially if there's any young women out there who want to train to be a doctor or a nurse or a healthcare professional of some description. 

Susan: Well, I think first of all, be very open-minded. Not so open-minded your brains fall out, but be open-minded and challenge your own assumptions. Check the facts.

More and more we are discovering that the assumptions behind our beliefs are based on lies and misdemeanours. So fact checking is absolutely critical. And I think understanding biases and confounding and why research trials are important, these are really important basic things for young people to get into because you learn by delving deep. 

Even if you've just got a patient in front of you, delve deep about the condition or the symptom or their response, don't just take it for granted what you are taught and told, because that's how you become a much better observer, which is what you need in the consultation room as somebody walks in the door and their body language and the mismatches of what they say and how they say it and what they're saying they're feeling and the objective signs. Sometimes it's like Sherlock Holmes and solving a riddle. And sometimes it's important, because you make those observations, to be getting feedback all the time. You know, how am I driving? Ask people, how are the consultation around ask people who are observing you, how am I doing?

So it's a wonderful thing because you don't realise how ignorant you are at the start, but the more you learn, the more you actually become good at the job. 

You can often realise how much more ignorant you are then. Yeah. But I think living with uncertainty is very hard.

And when you're talking to someone who's got an uncertain future and has got bad news of one sort or another, and you can’t reassure you can always care and you can always be compassionate. Even when we can't cure, we can always care and it's wrong to not tell people the truth, the full truth, and nothing but the truth. But there are ways and ways of doing it extremely well and sensitively and in a way that is at the speed of the patient and you walk the journey with them. 

So I think these things come with practice and it's very hard because we all want to do our jobs well. And realising you haven't done your job well, means you've harmed someone.

It's not the same as putting up wallpaper that is un tasteful. What we do when it goes wrong is harmful. And what we do sometimes is we can't help someone while their disease is harming them. So the robustness that's needed to keep going through the times of adversity for your patients and the times of adversity for yourself is quite important too.

So you have to have a life outside and learn all the different forms of resilience.  and get lots of support from your mates and colleagues and the books and get the rest and recuperation and relaxation outside of work.

Sara: What action would you like our listeners to take to support an aspect of your work or something, a cause that you're interested in, for example?

Susan: Well, I think that opening lines of communication with people who think differently or who can generate the data that you are interested in or that you can supply is important. I would like a lot more people to read about the science and the mathematics and the medical books and keep talking. I think it's really important not to be taken in by the individualist consumerist culture that we have that's in medicine at the moment. And I think it's really important to know a lot about the social and commercial determinants of health. I'm sure FiLiA has people who have succumbed to the poisons of smoking and alcohol and recreational drugs.

I'm a doctor. I would dissuade people from some of those things. I'd much prefer that people are active. Transport is a feminist project. Activity is a feminist project. Air pollution is a feminist project.

They're feminist projects because women are poorer because they still mostly are bringing up the children and you know and when we see young activists like Greta Thunberg, we know we've got to do more. 

So you can't but be interested in all these things which are relevant to women's health because of our health, let alone the particular health of our female organs.

I think it's a feminist project to take on the commercialisation of bodies. You know, whether women's labour is being discussed at the level of decriminalising sex work or prostitution, whether women's labour in surrogacy is an issue. I think wider than that is that all bodies are now considered frail.

It used to be that the woman's body was more unreliable and she had a wandering womb and her mind wasn't good enough and all that. 

But I think what we've got now is a much subtle attack on all bodies and Donna Dickenson, the philosopher talks in her book Body Shopping about everyone having female bodies now the parts can be of value and can be bought and sold. So I think feminists have to look at the much wider health, wellbeing, medical project with much more sceptical eyes. 

Sara: Yeah, there's a lot of different work to be done.

Susan: But maybe the answer is to pick on one or two examples, exemplars, where something is being done extremely well, or an exemplar of something that's going wrong that exposes the fractures in the governance so that we can see where the vested interests lie, where the money's changing hands, where assumptions or prejudices apply. That concept of institutional and structural violence, whereby women are put in harm's way due to being women so when you see differences like that, you hold, not the individual to account for her plight, but the systems in which that plight is made more likely to happen.

So I think recognising and calling out some of the institutional and structural violence against women and girls could be very illuminating. You shine a light on one space and it shines lights on the structures. So, you know, one can be very strategic in choosing which thing to be angry about.

Otherwise we end up just being angry and ineffective and that doesn't get us very far. 

Sara: No. Plus there's probably too much to be angry about sometimes, maybe. 

Susan: Well, that's right. And I think one of the things that I'm really struck by, people like rape crisis is they actually talk about activism being cathartic and healthy. Not for everyone but if someone, it's like the idea of people who've got traumatic stress reactions to terrible things that have happened to them, you know, and if you were in a fire, some people who have come out from the fire want to supply buckets to the people who are still there or going in. And I think that seeing the opportunities for turning pain into power or empowering people, to take on what happened to them and to see it with the feminist lens. I mean, I think that is the great success of peer-led charities that are activists and what little evidence there is about what makes society change is that a thriving women's movement, an empowered feminist group are actually associated with societies that improve things.

So we absolutely must understand that power. but you know, behind that will be jobs and security and money and all, all the usual levers of power. But if there are feminist doctors or doctors who can provide data that is relevant to all women, feminists must make those liaisons.  

Sara: Thank you so much for talking with us and so graciously donating us your time and your wisdom. Thank you. 

Susan: It's been a pleasure.